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1. Impact on public health — Compliance component #1 of 5 <br />Compliance criteria: <br />Attached supp <br />System discharges sewage to the ❑ Yes' ® No <br />❑ Other: <br />ground surface <br />_ <br />®Not applicable <br />System discharges sewage to drain ❑ Yes' ®No <br />tile or surface waters. <br />System causes sewage backup into ❑ Yes' ® No <br />dwelling or establishment. <br />Any "yes" answer above indicates the system is an <br />imminent threat to public health and safety. <br />Describe verification methods and results: <br />Searched for surface outlet or ground discharge <br />Checked for back-up <br />2. Tank Intel <br />— Compliance component #2 of 5 <br />System consists of a seepage pit, ❑Yes' ®No __ <br />cesspool, drywall, leaching pit, <br />or other pit? <br />Sewage tank(s) leak below their ❑ Yes' ® No <br />designed operating depth? <br />If yes which sewage tank(s) leaks: I <br />Any "yes" answer above indicates the system <br />is failing to protect groundwater. <br />Describe verification methods and results: <br />Pumped & Inspected <br />https://www,pca.state,mn.us 651-296-6300 800-657-3864 <br />wq-wwists4-31b • 1/11/21 <br />documentation: <br />Attached supporting documentation: <br />® Pumped at time of nspection <br />Name of maintenar ce business: Sewer Services <br />License number of maintenance business: 2502 <br />Date of maintenance: 1/17/2022 <br />❑ Existing tank integrty assessment (Attach) <br />Date of maintenance <br />(mmiddiyyyy): (must be within three years) <br />(See form instructic ns to ensure assessment complies with <br />Minn. R. 7082.070( subp. 4 8 (1)) <br />❑ Tank is Noncompliant (pumping not necessary - explain below) <br />❑ Other. <br />I <br />Use your referred relayservice Available in alternative formats <br />Page 2 of 4 <br />